Occupant Health Benefits of Residential Energy Efficiency November 2016

An E4The Future, Inc. White Paper

Foreword Steve Cowell, E4TheFuture

Energy efficiency (EE) creates many sources of value beyond just reducing energy costs. Recognition and acknowledgement of these multiple benefits is on the rise. Energy efficiency enhances system sustainability and builds energy security, supports economic development by creating new jobs, reduces disproportionate energy burdens borne by low-income customers, and improves public health by reducing outdoor air pollution caused by power plant emissions. More recently, there is increased interest in understanding the potential home occupant health benefits of EE investments due to improved indoor air quality, safety, and comfort. EE providers are exploring ways to work with health partners to leverage the EE workforce. While delivering EE, workers can identify opportunities that may improve health outcomes, particularly for occupants with pre-existing health risks linked to their home environment. To help inform and prompt discussion across a range of audiences on these health co-benefits from residential EE investments, E4TheFuture engaged a team of experts. Our goal was to review existing research on residential EE measures and associated health impacts, discuss ways that programs monetize occupant health co-benefits, highlight innovative programs that combine EE and health-focused home repairs, and identify research gaps and strategies to help advance and leverage funding across such integrated efforts. E4TheFuture is pleased to present this paper, with its key findings and recommendations. We encourage residential EE program administrators, implementers, regulators, funders, and advocates to build their knowledge and understanding of the potential occupant health benefits of EE activities, as well as the methodologies to fully value health co-benefits in EE program cost-effectiveness practices1.

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A forthcoming publication of a National Standard Practice Manual for Cost-Effectiveness Screening (2017), being developed by the Home Performance Coalition, will provide additional principles and guidance on identifying and quantifying non-energy benefits.

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Project Team About Tohn Environmental Strategies (TES) Tohn Environmental Strategies is an environmental and health policy consulting firm with over 25 years of experience in environmental health, healthy housing, green building, indoor air quality and lead poisoning prevention. TES has advised Federal and state agencies and non-profit organizations in designing healthy housing and indoor air quality elements for green building and energy retrofit programs; developed green and healthy housing programs; conducted environmental health research studies; provided strategic planning at the intersection of health, housing and energy efficiency; and worked with property owners, developers and managers to design, construct and manage green and healthy housing. About The National Center for Healthy Housing (NCHH) NCHH, a nonprofit corporation, is dedicated to developing and promoting practical, validated, and effective methods to address residential environmental health hazards. Founded as the National Center for Lead-Safe Housing in 1992, NCHH is the nation’s principal proponent of evidence-based policies and techniques for identifying and reducing health hazards in our nation’s housing stock. Since its inception, NCHH has managed over 100 multi-disciplinary projects totaling over $20 million. NCHH’s staff includes housing, health, and environmental experts in biostatistics, environmental health, public health, housing policy, toxicology, and industrial hygiene. It has worked with a broad array of stakeholders including federal, state, and local agencies, universities, and private research institutions and has published and contributed to over fifty articles and reports on environmental health and housing issues. About Three3 The mission of Three3 is to foster equitable, sustainable futures. It is widely accepted that the three components, or pillars of sustainability, are environment, equity, and economics, in combination. Three3 conducts innovative, interdisciplinary research and offers educational programming to promote the integrated achievement of sustainability goals in these areas. We provide research and evaluation services, with particular expertise in energy efficiency; program evaluation and sustainability planning support; and facilitation services to support sustainable development. About E4TheFuture (E4) E4TheFuture is a nonprofit organization working to advance safe, efficient energy solutions with a focus on residential customers. “E4” encompasses: promoting clean, efficient Energy; growing a low-carbon Economy; ensuring Equity by providing all Americans with clean, efficient, affordable energy; and restoring a healthy Environment for people, prosperity and the planet. Our endowment and primary leadership comes from Conservation Services Group (CSG), which provided low-cost clean energy solutions 1984-2015 in over half of U.S. states helping to improve more than 3.8 million homes.

Acknowledgements: We would like to thank Gary Adamkiewicz, Harvard School of Public Health and Kevin Kennedy, Children’s Mercy Hospitals and Clinics for their review and comments in the preparation of this document.

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Table of Contents Common Acronyms ................................................................................................................................ 5 Executive Summary ................................................................................................................................ 6 I.

Introduction ................................................................................................................................... 9

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Potential Occupant Health and Indoor Environmental Improvements ....................................... 10

III. What the Studies Tell Us .............................................................................................................. 12 Interpreting Health Study Results ........................................................................................... 12 Summary of EE and Ventilation Projects Evaluated ................................................................ 13 Respiratory Related Benefits from EE ..................................................................................... 16 General and Mental Health Benefits From EE......................................................................... 19 Respiratory Related Benefits From Ventilation....................................................................... 21 IV. Monetary Value of Occupant Health Benefits ............................................................................. 22 V.

Innovative Energy and Health Programs ..................................................................................... 25

VI. A Road Map for Action ................................................................................................................. 28 References ........................................................................................................................................... 31 Appendix A: DOE WAP National Evaluation ........................................................................................ 34

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Common Acronyms ASHRAE: American Society of Heating Refrigeration and Air Conditioning Engineers CO: Carbon Monoxide CO2: Carbon Dioxide COPD: Chronic Obstructive Pulmonary Disease ED: Emergency Department ERV: Energy Recovery Ventilator HRV: Heat Recovery Ventilator HVAC: Heating, Ventilation, and Air Conditioning NO2: Nitrogen Dioxide NEBs: Non Energy Benefits NEIs: Non Energy Impacts OR: Odd Ratio pCi/L: Picocuries per Liter RH: Relative Humidity WAP: Weatherization Assistance Program

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Executive Summary Residential energy efficiency (EE) program administrators and other stakeholders are increasingly interested in understanding the potential occupant health benefits of EE upgrades in homes, and the methodologies to fully value health co-benefits in EE program cost-effectiveness practices. Interest is growing in exploring opportunities to work with health partners to leverage the EE workforce to improve health outcomes, particularly for those with pre-existing health risks linked to their home environment. To help inform and prompt discussion across a range of audiences on the health co-benefits from residential EE investments, this paper reviews research studies of residential EE and related ventilation upgrades, discusses ways that programs have monetized occupant health co-benefits, and highlights innovative programs that combine EE and health-focused home repairs. The paper concludes with identifying research gaps and strategies to help advance such work. This paper focuses on research studies conducted in the United States (US) and Canada. It includes one international study due to its robust findings. Importantly, this paper builds upon a broader literature review conducted by the US Department of Energy (DOE), Home Rx: The Health Benefits of Home Performance: A Review of Current Evidence, which was developed to summarize studies that evaluated occupant health related outcomes associated with energy upgrades and home performance improvements. The DOE report considers both US and international studies. Potential Occupant Health Impacts From Residential EE Residential EE programs typically improve the building envelope and heating systems, creating warmer and more comfortable homes. The pathways by which home energy upgrades can also help to improve indoor environmental conditions and occupant health is shown in Figure ES1. Figure ES1: Occupant Health and Indoor Environmental Benefits of Residential EE Insulation Air Sealing Heating System Upgrades C Ventilation Vent Dryers

Less moisture, mold, particulates, pollutants, combustion byproducts, allergens

Efficient Cooking Appliances

Fewer heat or cold related deaths Less hypertension, heart disease Fewer asthma, respiratory, Chronic Obstructive Pulmonary Disease risks

Fewer heart disease risks, headaches Fewer cancer risks due to radon, formaldehyde, other sources

Lower bills, better comfort

Reduced hospital or medical visits

Warmer drier air, improved indoor temperatures & relative humidity

Less stress, better mental health

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What the EE Studies Tell Us Twelve studies of residential EE and two studies of related ventilation strategies all document some improvement in occupant health or indoor environmental conditions. Some studies also observed reductions in asthma or respiratory related emergency department (ED) or hospital visits. Results of the EE studies are summarized in Table ES1 below. Table ES1: Occupant Health Benefits of Residential EE Reduced Respiratory & Allergy Symptoms Allergies Asthma* Colds Sinusitis Throat irritation Wheeze

Other Health Improvements Headaches Hypertension Thermal stress Overall health Mental health

Reduced Emergency Dept. Visits or Hospitalizations Asthma Other respiratory

Indoor Environmental Conditions Moisture Condensation VOCs Formaldehyde Radon

Italics: some negative outcomes VOCs: Volatile Organic Compounds * The majority of studies reported asthma improvements; one study documented mixed results

Improvements in asthma symptoms and related health care use are significant because asthma affects roughly 1 in every 14 adults (7%) and a greater percentage of lower income adults (16% of adults in households receiving Department of Energy (DOE) funded weatherization). (CDC 2016; Tonn et al. 2014) Experts estimate that 40% of diagnosed asthma is associated with home exposures (e.g., moisture, temperature variations, pests), some of which can be improved through EE and related ventilation. (RWJ 2009) Key study findings are presented below; examples of research findings described in the full report are also highlighted.  Occupants can experience fewer asthma symptoms and respiratory related ED visits after EE.  Occupants report better physical and mental health after EE.  Programs delivering EE with added home repairs and client education can produce more significant improvements in asthma symptoms and indoor environmental conditions.  Improvements in occupant health are strongest among vulnerable groups: lower income households and residents with pre-existing health conditions linked to housing risks.

12% fewer asthma ED visits and 48% decline in poor health among adults in households receiving DOE funded weatherization Tonn et al. 2014 23% reduction in poorly controlled asthma for children in homes receiving EE, some home repairs & education compared to those receiving only education Breysse et al. 2014

 Whole house ventilation strategies using heat or energy recovery ventilators (HRVs or ERVs) can reduce asthma and respiratory symptoms in children with pre-existing risks. Such strategies are increasingly being considered in EE programs.  Homes receiving EE can experience increases in radon or formaldehyde; ventilation systems may offer the potential to reduce radon in such homes. Tohn Environmental Strategies * The National Center for Healthy Housing * Three3

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 The majority of studies were conducted in single family lower income homes located in predominately northern heating climates. Given this evidence, it is not appropriate to value the health co-benefits of low income residential energy retrofits at $0 in program design or cost-effectiveness practices. Innovative Energy and Health Programs Are Testing New Models EE programs are testing innovative approaches and developing new partnerships to improve occupant health. Some programs offer integrated energy and health home upgrades. Others are linking EE programs with health referrals and building strong local collaborations. Often these programs are targeting clients with pre-existing respiratory or other housing-based health risks. Of importance is the relatively new Building Performance Institute (BPI) Healthy Homes Evaluator Credential, which provides added health training to the EE workforce. This certification program can help to support these new innovative programs. A Road Map for Action Studies show that residential EE programs can help to improve occupant health. To help promote EE programs that improve health and engage health partners, we should pursue four key activities. These are described in more detail beginning on page 28.

1. Share Results

2. Support Innovative Programs

 Widely distribute occupant health research to energy and health partners  Engage energy regulators to incorporate occupant health co-benefits into program design and cost-effectiveness practices

 Support EE programs addressing occupant health and engaging health partners  Promote funding models, work practices, evaluation, and health collaborations

3. Fill Research Gaps

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4. Define & Share Best Practices

 Promote EPA Guidance on health benefits during energy upgrades  Update guidance and tools to reflect current research and best practices

Assess EE and health focused home repairs for clients with respiratory risks Evaluate practices to minimize radon and formaldehyde risks Examine EE in warm climates, market rate, and multifamily homes Pursue studies with comparison groups to provide robust results

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I.

Introduction

Residential energy efficiency (EE) upgrades to building envelopes and heating systems can improve indoor environmental conditions and create healthier living conditions. This has been demonstrated in particular in low income weatherization programs. Occupant health benefits are of increasing interest to those designing, funding, and delivering energy programs in both low income and nonlow income homes, as well as to healthcare system partners. This report addresses key questions being asked by EE program administrators and other stakeholders: 1. To what extent do EE programs and practices help to improve the health of occupants by reducing asthma risks, respiratory symptoms, and other health risks linked to home conditions? 2. Have we fully or appropriately valued the occupant health co-benefits of EE programs in program cost-effectiveness screening practices? 3. How might EE programs be modified to better identify occupants with health risks and create greater health benefits, in both low income and non-low income homes? How can the EE industry work with healthcare system partners to leverage the EE workforce to improve health outcomes? 4. What additional research is needed to better understand the health impacts of EE programs? This report addresses these questions by reviewing health impact research of residential EE programs and related ventilation improvements (Section II & III), discussing ways programs have monetized occupant health co-benefits (Section IV), and providing examples of innovative programs that combine home EE upgrades with health focused home repairs or occupant education (Section V). Finally, we offer recommendations in a Roadmap for Action (Section VI) to widely share what is known about health benefits of EE, support innovative collaborative program models and best practices, and address research gaps. The research review focuses on studies conducted in the United States (US) and Canada, given the consistency of the housing stock. One international study is referenced because it provides particularly robust findings. Information about innovative EE programs that are integrating health priorities or partners was gathered from websites, webinars, and interviews. Importantly, the report builds upon a broader literature review conducted by the U.S. Department of Energy (DOE) and international studies relevant to the EE and home performance industries. DOE’s report, entitled Home Rx: The Health Benefits of Home Performance: A Review of Current Evidence, summarizes a wide range of studies and identifies research gaps related to: EE, ventilation, green renovation and construction, and supplemental home services that home performance contractors might undertake to create healthier living environments.

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II.

Potential Occupant Health and Indoor Environmental Improvements

While most residential EE work is not focused on improving occupant health, common EE activities can create a drier home with more consistent temperatures, fewer air indoor pollutants, reduced allergens, and fewer asthma triggers (changes in temperatures, dampness, mold, mice or cockroach droppings). Such changes have the potential to reduce resident health risks as depicted in Figure 1 and discussed below. In general, most research studies assess the health impact of a bundled set of EE services and not specific EE actions. Figure 1: Occupant Health and Indoor Environmental Benefits of Residential EE Insulation Air Sealing Heating System Upgrades C Ventilation Vent Dryers

Less moisture, mold, particulates, pollutants, combustion byproducts, allergens

Efficient Cooking Appliances

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Less hypertension, heart disease Fewer asthma, respiratory, Chronic Obstructive Pulmonary Disease risks

Fewer heart disease risks, headaches Fewer cancer risks due to radon, formaldehyde, other sources

Lower bills, better comfort

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Fewer heat or cold related deaths

Reduced hospital or medical visits

Warmer drier air, improved indoor temperatures & relative humidity

Less stress, better mental health

Asthma and Other Respiratory Symptoms Approximately 7% of the US population is affected by asthma; 16% of adults in the Weatherization Program National Evaluation reported having asthma. (Tonn et al. 2014; CDC 2016) Living in a home with moisture/dampness, mold, pests (cockroaches or mice), cold or inconsistent temperatures, environmental tobacco smoke, dust mites, or indoor air pollutants can increase the risks of asthma attacks, wheezing, and other respiratory symptoms. (RWJ 2009; Fisk et al. 2007). Air sealing and insulation can improve indoor temperatures, reduce dampness or moisture issues, and exclude mice and cockroaches. Repairs or upgrades to HVAC system, as well as new tight windows and doors, can help reduce air pollutants. Chronic Obstructive Pulmonary Disease (COPD) Symptoms in Adults COPD refers to a group of diseases that cause airflow blockage and breathing-related problems, including emphysema and chronic bronchitis. According to the Centers for Disease Control (CDC), approximately 15 million adults report COPD (6% of adults) and it is the third leading cause of death among US adults. (CDC 2016) Improving indoor temperatures to create warmer homes, and reducing fine particulate matter and air pollutants through improved

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ventilation and heating system/cooking appliance upgrades, can help to reduce potential COPD risks. Allergy and Sinus Infection Risks Allergies may affect up to 30% of adults and 40% of children; 12% of adults have sinusitis (sinus infections). (AAFA 2016; CDC 2016) EE that addresses home moisture, mold, cold temperatures, and pests through air sealing and insulation, can reduce some allergens and potential risks for sinus infections. Controlling the infiltration of outdoor air through air sealing, improved air filtration, installation of new doors and windows, and upgraded HVAC systems, can also help to reduce exposure to outdoor allergens. Cancer Risks The Environmental Protection Agency (EPA) estimates that 21,000 lung cancer cases per year are associated with radon exposure. (EPA 2003) Radon exposures can be minimized through ventilation and air sealing. Formaldehyde exposures, also linked to cancer, may be reduced through enhanced ventilation. Hypertension and Cardiovascular Risks Approximately 30% of Americans struggle with hypertension, a risk factor for cardiovascular risks. (CDC 2015) Improvements in indoor temperatures and reduction of particulates from outdoor air (by filtration of outdoor air in heating systems and/or air sealing) can help to reduce conditions that can exacerbate hypertension. Headaches EE activities can reduce moisture through air sealing and insulation, reduce exposure to indoor air contaminants through heating system/cooking appliance upgrades and ventilation, and stabilize indoor temperatures. Such improvements may help to reduce headache risks in some individuals. Death or Injuries Due to Extreme Heat or Cold, Carbon Monoxide Poisoning, Or Fires Exposure to extreme heat, cold, carbon monoxide (CO) or fires can result in death. CO exposures can also create headaches, dizziness, weakness, upset stomach, vomiting, chest pain, confusion, or “flu-like” symptoms. Many EE programs test and address harmful CO emissions from combustion appliances and install CO alarms to prevent future exposures. Fire risks can be reduced by addressing electrical wiring risks and faulty combustion appliances. Installation of smoke detectors can help prevent fire-related injuries or death. Overall Physical Health General physical health is impacted by exposures to extreme cold or heat, dampness, indoor air contaminants, and stress which can exacerbate other poor health outcomes. EE interventions can improve these home environmental conditions and reduce financial hardships that can increase stress (difficulty paying energy bills in lower income families) by lowering household fuel bills. Mental Health Mental health can be impacted by both physical environmental conditions and financial hardships due to fuel bills. EE can help make homes warmer or reduce temperatures in homes prone to overheating, reduce high energy bills which can create stress, and improve environmental conditions that can disrupt sleep (dampness, cold, air contaminants).

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III.

What the Studies Tell Us

We reviewed a total of 14 studies that examined the occupant health or indoor environmental benefits of residential EE and/or ventilation upgrades. A range of core EE measures were undertaken, which included: insulation, air sealing, and heating system repairs/upgrades. Enhanced ventilation, additional housing repairs, and/or occupant education were added to core EE in several studies. One study examined window replacements. Ventilation-only retrofits were also evaluated to provide insights on this specific measure, which is being considered in EE programs that are increasing building tightness and exploring mechanical ventilation strategies. The studies tracked several outcome metrics: 1) the health of those living in the homes (i.e., occupant health), 2) occupant health care utilization or health care costs, and 3) indoor environmental conditions. The collective impact of these three health related metrics is summarized into two broad categories: fewer respiratory symptoms or improvements in general physical or mental health (Figure 2). We describe the study results using these two categories. The report also summarizes the benefits of stand-alone ventilation studies in a separate subsection. Figure 2: Occupant Health Improvements From EE

Fewer respiratory symptoms Energy Efficiency Better general or mental health

Interpreting Health Study Results The majority of studies focused on occupant health as the key outcome metric. Occupant health was typically measured based on occupant self-reports using validated health questionnaires. Validated questionnaires have been tested to demonstrate that interviewees will provide similar responses when their health conditions are similar. Occupant self-reported health has been shown to be a good predictor of clinical health. In a few cases, researchers tracked empirical health measures (e.g., lung function, blood pressure). Most studies looked at health effects over a one- to two-year window after the EE measures were installed. A few studies tracked the impact of the EE on health care utilization or health care costs. Health care utilization was tracked through occupant surveys or a review of health care claims (e.g., Medicaid). Health care costs were measured through reviews of health records (e.g., Medicaid costs) or through monetization of occupant reported health care use. Several studies measured indoor environmental conditions, which were tracked through occupant self-reports; on-site observations from trained staff; or environmental sampling (air sampling, dust allergens, and/or data loggers). Tohn Environmental Strategies * The National Center for Healthy Housing * Three3

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In terms of the level of certainty in the study results and strength of the study design, we note three factors: a) the extent to which comparison groups were used, b) the targeting of individuals with pre-existing health risks, and c) the statistical significance of the results, which provides a way to assess our confidence in the observed outcome. In general, studies with a control or comparison group can produce more robust results because they can demonstrate that changes are related to EE and not to other factors influencing occupant health or environmental conditions in similar households. Studies that enroll individuals with pre-existing health conditions (versus studies that enroll homes needing EE with no knowledge of occupant health risks) have a greater likelihood of documenting health improvements and reductions in health care use because they focus on a population at greater risk. The criteria used to report statistical results are discussed below. The report describes results where there is a high degree of confidence that the changes observed were due to the EE or ventilation work. We present results that have a statistical significance at a value generally accepted by the health research community (p